THE BURDEN OF HEALTH CARE
This isn’t about all the discomforts that are endured while actually undergoing evaluation and examination; the uncomfortable questions, the squeezing, poking or the prodding of body parts. This also isn’t about the discomforts of treatment; medication side effects or pain of more invasive procedures. Not that those things don’t amount to a significant burden but let’s leave that for another time.
I’m talking about the burden endured in the initial steps of seeking help with a physical ailment. The problem that must be solved before anything else is figuring out where to go first. You may be lucky enough to have a great primary care provider who is well connected with every type of specialist. Maybe, and just maybe, that primary doctor can identify and solve your problem with one visit but if not then you are burdened with multiple tests and treatment over some period of time. Each office visit might require time off from work, sometimes without pay, or even worse, also time off for a spouse, possible without pay as well. In Boston, where I practice, getting in to my centrally located office requires a trip whose duration can’t be predicted particularly during peak traffic times. Nearly every day that I see patients, I hear of the stress this creates as these patients call to report that they are running late and I see it in their faces when they finally arrive. Did I mention that they have to pay ridiculous amounts to park in our hospital parking lot? And, No, sir we don’t validate.
Once they finally arrive in my office, the first thing we ask of patients is to fill out a lengthy multipage form that asks for the details of their medical history and present complaints. They also fill out multi-question “outcomes instruments” that we collect to track results of our treatment. Each time they visit us they fill those instruments out again. These typically ask about pain and function. Some outcomes questionnaires are 30 or 40 questions long! Years ago, someone thought the use of the MMPI might be useful. It originally contained 567 items but was restructured down to 338. No burden there (eye roll).
Very often they need imaging or consults that I gladly and can usually arrange to be done immediately, or within a few hours. Unfortunately, many have insurance that requires someone on my staff to call for approval. Those phone calls can take up to 30 minutes or more, most of it on hold. I just don’t have enough staff that can sit on hold on a phone while juggling other calls and greeting patients. And if a physician to physician, so-called “peer review” is needed, well, that just isn’t going to happen that day. So, you guessed it, the patient has to take more time off work, schlep through traffic, pay for parking yet again as well as another co-pay. The most frustrating part of the approval process for me is that the answer is virtually always yes. Think about the amount of resources that are poured in to “utilization review”. One wonders how often the answer is yes anyway.
I haven’t even discussed the burden of actual treatment and I won’t. In my specialty, spine surgery, post-surgical follow-up visits are necessary, often up to 5 or more over time. Mostly I’m asking how things are going, are you sticking to recommended diets, activity levels and medications. Many surgeons will obtain x-rays with each visit regardless of the utility of doing so. For someone who is doing well, that visit can take mere minutes. Yet the entire process, from leaving home to finally returning, can take many hours.
I hope my point is becoming clear. The burden of just getting to a doctor, getting the right care and following up, is tremendous. I haven’t factored in lost wages and productivity, co-pays and out of pocket expenses. Is it any wonder that the elderly, those with chronic or disabling conditions, children or the poor don’t get adequate or timely health care?
We live in a time of exploding technology. The health start-up world is blazingly hot right now, developing enabling technology and applications that could significantly reduce the burden on patients. Much already exists but is not widespread. Entering medical and health information online before going to the doctor’s office, providing patient reported outcomes using computer adaptive testing and telemedicine or virtual house calls. Wearable technology allows the doctor to monitor vitals signs, blood levels of glucose or drugs and overall physical activity levels. There are Smartphone applications and plugin devices that can perform breathing tests, urinalysis and relay photos of surgical wounds. If someone could just devise a way to perform virtual physical exams we just might be able to eliminate office visits altogether. I can already hear the pushback about lack of the power of touch and face-to-face human interaction but couldn’t this technology find a role to lessen the burden at least some of the time?
I can envision my office functioning with some of this technology. My patients could book their visit online, verify insurance coverage, pay their co-pay, upload their imaging, provide medical history and background information, fill out the patient reported outcome instrument and describe symptoms within a templated application all before arriving at my office. After our visit, I could provide a detailed care plan and they could provide feedback about progress. If surgery were recommended, they might have detailed access to video descriptions of the procedure, risks and benefits and recovery process. They could follow-up virtually without the need to come in to the office, obtain imaging locally if possible and upload activity levels or other parameters via smartphone applications. They could send photos of their surgical wound so I could monitor for healing or signs of infection. They could provide periodic outcomes measures through the use of computer adaptive testing methods. I might only need to see them if they desire or if there are problems that need close attention. Hopefully, this facilitated connection could allow earlier intervention to minimize these problems. I know much of this technology exists already but only as disparate, one-offs. Why not create an integrated suite of applications that address the unique and mutual needs of patients and doctors alike? Anyone want to join me in creating this future?